Status of inhaler technique and influencing factors among patients with chronic respiratory diseases in southwest China_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

WU Xiaoyan ¹ ,  FENG Mei ¹ ,  WU Ying ¹ , LIAO Lei ² , YANG Jinyu ³ , DENG Li ⁴ , ZHANG Xingyan ⁵ , MU Fang ⁶ , ZHONG Hui ⁷ , RAO Chunyan ⁸

1. Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Chengdu Third People's Hospital, Chengdu, Sichuan 610000, P. R. China;
3. Mianyang Third People's Hospital, Mianyang, Sichuan 621000, P. R. China;
4. Mianyang Central Hospital, Mianyang, Sichuan 621000, P. R. China;
5. Jintang County First People's Hospital,, Jintang, Sichuan 610400, P. R. China;
6. Guangyuan Central Hospital, Guangyuan, Sichuan 628000, P. R. China;
7. Yibin Second People's Hospital, Yibin, Sichuan 644000, China;
8. Chengdu Seventh People's Hospital, Chengdu, Sichuan 610000, China;

Corresponding?author：

FENG Mei, Email: fm197711@wchscu.cn; WU Ying, Email: wuying0917@wchscu.cn

Keywords：

Chronic respiratory diseases; inhalers; medication errors; decision making

DOI：

10.7507/1671-6205.202510022

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To assess inhaler technique among patients with chronic respiratory diseases in Southwest China, and identify key physiological and psychological factors affecting correct inhaler use. Methods This was a multicenter cross-sectional study. Inhalation operation technique was assessed using a self-developed scale. Inhaler proficiency of participants was assess by critical error occurrence, and the pass rate was calculated accordingly. Binary logistic regression was applied to identify factors associated with critical errors, including variables with P<0.1 from univariate analysis in a multivariate model. Variable selection was performed using a stepwise method. Results A total of 336 inhalation device users from 8 central hospitals in Sichuan Province were enrolled. The overall error rate of inhalation device use was 87.2%. Among dry powder inhaler users, 21.4% failed to achieve the inspiratory flow rate required by the device. Among pressurized metered-dose inhaler users, 35.71% were unable to achieve hand-mouth coordination after three operation attempts. Binary logistic regression analysis showed that forgetfulness experience (OR=0.389, 95%CI 0.156-0.970) and inspiratory flow rate (OR=0.977, 95%CI 0.964-0.989) had statistically significant effects on correct device use. No statistically significant psychological factors were identified in this study. Conclusions Incorrect inhaler use is highly prevalent among patients with chronic respiratory diseases in Southwest China, with many unable to meet the inspiratory flow requirements of their devices. Low inspiratory flow and operational forgetfulness may contribute to poor inhaler technique.

Citation： WU Xiaoyan, FENG Mei, WU Ying, LIAO Lei, YANG Jinyu, DENG Li, ZHANG Xingyan, MU Fang, ZHONG Hui, RAO Chunyan. Status of inhaler technique and influencing factors among patients with chronic respiratory diseases in southwest China. Chinese Journal of Respiratory and Critical Care Medicine, 2026, 25(7): 469-476. doi: 10.7507/1671-6205.202510022 Copy

1.	Gbd Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med, 2020, 8(6): 585-596.
2.	Liu H, Yin P, Qi J, et al. Burden of non-communicable diseases in China and its provinces, 1990–2021: Results From The Global Burden Of Disease Study 2021. Chin Med J (Engl), 2024, 137(19): 2325-2333.
3.	Tabaza H, Farha RA, Gharaibeh L, et al. Length of hospital stay and its predictions among patients with exacerbations of chronic respiratory diseases. J Eval Clin Pract, 2025, 31(1): e14308.
4.	Anderson S, Atkins P, B?ckman P, et al. Inhaled medicines: past, present, and future. Pharmacol Rev, 2022, 74(1): 48-118.
5.	Labiris NR, Dolovich MB. Pulmonary drug delivery. Part II: The role of inhalant delivery devices and drug formulations in therapeutic effectiveness of aerosolized medications. Br J Clin Pharmacol, 2015, 56(6): 600-612.
6.	Courrier HM, Butz N, Vandamme TF. Pulmonary drug delivery systems: recent developments and prospects. Crit Rev Ther Drug Carrier Syst, 2002, 19(4-5): 425-498.
7.	Sánchez-Nieto JM, Andújar-Espinosa R, Bernabeu-Mora R, et al. Efficacy of a self-management plan in exacerbations for patients with advanced COPD. I Int J Chron Obstruct Pulmon Dis, 2016, 11: 1939-1947.
8.	Kocks J, Bosnic-Anticevich S, Van Cooten J, et al. Identifying critical inhalation technique errors in dry powder inhaler use in patients with COPD based on the association with health status and exacerbations: findings from the multi-country cross-sectional observational pifotal study. BMC Pulm Med, 2023, 23(1): 302.
9.	Nash D. Poor Inhaler adherence and techniques -- how can we improve It?. Curr Geri Rep, 2021, 10(2): 66-71.
10.	Barnestein-Fonseca P, Vázquez-González N, Martín-Monta?ez E, et al. The clinical relevance of inhalation technique in chronic obstructive pulmonary disease patients. Med Clin (Barc), 2022, 158(10): 472-475.
11.	Hesso I, Nabhani Gebara S, Greene G, et al. A quantitative evaluation of adherence and inhalation technique among respiratory patients: an observational study using an electronic inhaler assessment device. Int J Clin Pract, 2020, 74(2): E13437.
12.	Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med, 2008, 102(4): 593-604.
13.	Tamiya H, Mitani A, Abe T, et al. Association between inhalation instruction method in community pharmacies and inhaler device handling error in patients with obstructive lung disease: an evaluation of the impact of practical demonstration by pharmacists. Biol Pharm Bull, 2022, 45(12): 1764-1771.
14.	Rodriguez-Garcia C, Barreiro E, Mu?oz-Gall X, et al. Common errors in inhalation therapy: impact and solutions. Clin Respir J, 2020, 14(11): 1001-1010.
15.	Agustí A, Celli BR, Criner GJ, et al. Global Initiative For Chronic Obstructive Lung Disease 2023 Report: Gold Executive Summary. Eur Respir J, 2023, 61(4): 2300239.
16.	Miravitlles M, Soler-Catalu?a JJ, Alcázar B, et al. Factors affecting the selection of an inhaler device for COPD And the ideal device for different patient profiles. Results of Epoca Delphi Consensus. Pulm Pharmacol Ther, 2017, 48: 97-103.
17.	Hanania NA, Braman S, Adams SG, et al. The Role of inhalation delivery devices in COPD: perspectives of patients and health care providers. Chronic Obstr Pulm Dis, 2018, 5(2): 111-123.
18.	Anzueto A, Cohen M, Echazarreta AL, et al. Delphi consensus on clinical applications of gold 2023 recommendations in COPD management: how aligned are recommendations with clinical practice? Pulm Ther, 2024, 10(1): 69-84.
19.	von Elm E, Altman DG, Egger M, et al. STROBE initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet, 2007, 370(9596): 1453-1457.
20.	Mccrossan P, Mallon O, Shields MD, et al. How we teach children with asthma to use their inhaler: a scoping review. Ital J Pediatr, 2022, 48(1): 52.
21.	Pearce CJ, Chan AHY, Jackson T, et al. Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: a narrative systematic review. Pediatr Pulmonol, 2022, 57(4): 822-847.
22.	劉祥敏, 吳穎, 楊翠, 等. 基于Delphi-AHP法慢性氣道疾病吸入裝置使用關鍵技術評價表構建. 中國呼吸與危重監護雜志, 2024, 23(10): 685-690.
23.	Leontitsis A, Pagge J. A simulation approach on Cronbach’s alpha statistical significance. Math Comput Simulat, 2007, 73(5): 336-340.
24.	Mehnert A, Herschbach P, Berg P, et al. Fear of progression in breast cancer patients-validation of the short form of the Fear of Progression Questionnaire (FoP-Q-SF). Z Psychosom Med Psychother, 2006, 52(3): 274-288.
25.	陳娟, 雷明, 李沙沙, 等. 慢性阻塞性肺疾病患者使用吸入裝置的用藥評價與分析. 中國臨床藥理學雜志, 2019, 35(11): 1179-1182.
26.	何勝東, 楊樹棟, 何新兵, 等. 慢性阻塞性肺疾病患者干粉吸入裝置操作錯誤情況及影響因素研究. 中國全科醫學, 2020, 23(7): 819-823.
27.	Horváth A, Farkas á, Szip?cs A, et al. Numerical simulation of the effect of inhalation parameters, gender, age and disease severity on the lung deposition of dry powder aerosol drugs emitted by Turbuhaler?, Breezhaler? And Genuair? in COPD patients. Eur J Pharm Sci, 2020, 154: 105508.
28.	Baloira A, Abad A, Fuster A, et al. Lung deposition and inspiratory flow rate in patients with chronic obstructive pulmonary disease using different inhalation devices: a systematic literature review and expert opinion. Int J Chron Obstruct Pulmon Dis, 2021, 16: 1021-1033.
29.	Tarsin W, Assi KH, Chrystyn H. In-vitro intra- and inter-inhaler flow rate-dependent dosage emission from a combination of budesonide and eformoterol in a dry powder inhaler. J Aerosol Med, 2004, 17(1): 25-32.
30.	Schreiber J, Sonnenburg T, Luecke E. Inhaler devices in asthma and COPD patients -- a prospective cross-sectional study on inhaler preferences and error rates. BMC Pulm Med, 2020, 20(1): 222.
31.	Talaat M, Si X, Xi J. Effect of Mdi actuation timing on inhalation dosimetry in a human respiratory tract model. Pharmaceuticals (Basel), 2022, 15(1): 61.
32.	Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College Of Chest Physicians/American College Of Asthma, Allergy, And Immunology. Chest, 2005, 127(1): 335-371.
33.	Ding B, Small M, Scheffel G, et al. Maintenance inhaler preference, attribute importance, and satisfaction in prescribing physicians and patients with asthma, COPD, or asthma-copd overlap syndrome consulting for routine care. Int J Chronic Obstr, 2018, 13: 927-936.
34.	Trushenko NV, Stoliarevich AA, Andriukov BG, et al. Assessment of inhalation technique in patients with bronchial asthma and chronic obstructive pulmonary disease. Ter Arkh, 2023, 95(3): 210-216.
35.	Marko M, Pawliczak R. Inhalation technique-related errors after education among asthma and COPD patients using different types of inhalers - systematic review and meta-analysis. NPJ Prim Care Respir Med, 2025, 35(1): 15.
36.	Dabrowska M, Luczak-Wozniak K, Miszczuk M, et al. Impact of a single session of inhalation technique training on inhalation skills and the course of asthma and COPD. Respir Care, 2019, 64(10): 1250-1260.
37.	Harb HS, Laz NI, Rabea H, et al. First-time handling of different inhalers by chronic obstructive lung disease patients. Exp Lung Res, 2020, 46(7): 258-269.
38.	Melani AS, Bonavia M, Mastropasqua E, et al. Time required to rectify inhaler errors among experienced subjects with faulty technique. Respir Care, 2017, 62(4): 409-414.
39.	He JL, Xu HQ, Yang J, et al. Fear of disease progression among breast cancer patients in china: a meta-analysis of studies using the fear of progression questionnaire short form. Front Psychol, 2023, 14: 1222798.
40.	Finset A. Living well with COPD: illness beliefs, self-management support, patient involvement in decisions and inhaler education. Patient Educ Couns, 2020, 103(4): 675-676.
41.	中國醫學裝備協會呼吸病學專委會吸入治療與呼吸康復學組, 中國慢性阻塞性肺疾病聯盟. 穩定期慢性氣道疾病吸入裝置規范應用中國專家共識. 中華結核和呼吸雜志, 2019, 42(4): 241-253.
42.	Boise E, Rotella M. Abcs of asthma inhaler and device training. Int Forum Allergy Rhinol, 2015, 5 Suppl 1: S71-S75.
43.	Ahn JH, Chung JH, Shin KC, et al. The effects of repeated inhaler device handling education in COPD patients: a prospective cohort study. Sci Rep, 2020, 10(1): 19676.
44.	Brusselle G, Himpe U, Fievez P, et al. Evolving to a single inhaler extrafine LABA/LAMA/ICS - inhalation technique and adherence at the heart of COPD patient care (Trivolve). Respir Med, 2023, 218: 107368.

1. Gbd Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med, 2020, 8(6): 585-596.
2. Liu H, Yin P, Qi J, et al. Burden of non-communicable diseases in China and its provinces, 1990–2021: Results From The Global Burden Of Disease Study 2021. Chin Med J (Engl), 2024, 137(19): 2325-2333.
3. Tabaza H, Farha RA, Gharaibeh L, et al. Length of hospital stay and its predictions among patients with exacerbations of chronic respiratory diseases. J Eval Clin Pract, 2025, 31(1): e14308.
4. Anderson S, Atkins P, B?ckman P, et al. Inhaled medicines: past, present, and future. Pharmacol Rev, 2022, 74(1): 48-118.
5. Labiris NR, Dolovich MB. Pulmonary drug delivery. Part II: The role of inhalant delivery devices and drug formulations in therapeutic effectiveness of aerosolized medications. Br J Clin Pharmacol, 2015, 56(6): 600-612.
6. Courrier HM, Butz N, Vandamme TF. Pulmonary drug delivery systems: recent developments and prospects. Crit Rev Ther Drug Carrier Syst, 2002, 19(4-5): 425-498.
7. Sánchez-Nieto JM, Andújar-Espinosa R, Bernabeu-Mora R, et al. Efficacy of a self-management plan in exacerbations for patients with advanced COPD. I Int J Chron Obstruct Pulmon Dis, 2016, 11: 1939-1947.
8. Kocks J, Bosnic-Anticevich S, Van Cooten J, et al. Identifying critical inhalation technique errors in dry powder inhaler use in patients with COPD based on the association with health status and exacerbations: findings from the multi-country cross-sectional observational pifotal study. BMC Pulm Med, 2023, 23(1): 302.
9. Nash D. Poor Inhaler adherence and techniques -- how can we improve It?. Curr Geri Rep, 2021, 10(2): 66-71.
10. Barnestein-Fonseca P, Vázquez-González N, Martín-Monta?ez E, et al. The clinical relevance of inhalation technique in chronic obstructive pulmonary disease patients. Med Clin (Barc), 2022, 158(10): 472-475.
11. Hesso I, Nabhani Gebara S, Greene G, et al. A quantitative evaluation of adherence and inhalation technique among respiratory patients: an observational study using an electronic inhaler assessment device. Int J Clin Pract, 2020, 74(2): E13437.
12. Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med, 2008, 102(4): 593-604.
13. Tamiya H, Mitani A, Abe T, et al. Association between inhalation instruction method in community pharmacies and inhaler device handling error in patients with obstructive lung disease: an evaluation of the impact of practical demonstration by pharmacists. Biol Pharm Bull, 2022, 45(12): 1764-1771.
14. Rodriguez-Garcia C, Barreiro E, Mu?oz-Gall X, et al. Common errors in inhalation therapy: impact and solutions. Clin Respir J, 2020, 14(11): 1001-1010.
15. Agustí A, Celli BR, Criner GJ, et al. Global Initiative For Chronic Obstructive Lung Disease 2023 Report: Gold Executive Summary. Eur Respir J, 2023, 61(4): 2300239.
16. Miravitlles M, Soler-Catalu?a JJ, Alcázar B, et al. Factors affecting the selection of an inhaler device for COPD And the ideal device for different patient profiles. Results of Epoca Delphi Consensus. Pulm Pharmacol Ther, 2017, 48: 97-103.
17. Hanania NA, Braman S, Adams SG, et al. The Role of inhalation delivery devices in COPD: perspectives of patients and health care providers. Chronic Obstr Pulm Dis, 2018, 5(2): 111-123.
18. Anzueto A, Cohen M, Echazarreta AL, et al. Delphi consensus on clinical applications of gold 2023 recommendations in COPD management: how aligned are recommendations with clinical practice? Pulm Ther, 2024, 10(1): 69-84.
19. von Elm E, Altman DG, Egger M, et al. STROBE initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet, 2007, 370(9596): 1453-1457.
20. Mccrossan P, Mallon O, Shields MD, et al. How we teach children with asthma to use their inhaler: a scoping review. Ital J Pediatr, 2022, 48(1): 52.
21. Pearce CJ, Chan AHY, Jackson T, et al. Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: a narrative systematic review. Pediatr Pulmonol, 2022, 57(4): 822-847.
22. 劉祥敏, 吳穎, 楊翠, 等. 基于Delphi-AHP法慢性氣道疾病吸入裝置使用關鍵技術評價表構建. 中國呼吸與危重監護雜志, 2024, 23(10): 685-690.
23. Leontitsis A, Pagge J. A simulation approach on Cronbach’s alpha statistical significance. Math Comput Simulat, 2007, 73(5): 336-340.
24. Mehnert A, Herschbach P, Berg P, et al. Fear of progression in breast cancer patients-validation of the short form of the Fear of Progression Questionnaire (FoP-Q-SF). Z Psychosom Med Psychother, 2006, 52(3): 274-288.
25. 陳娟, 雷明, 李沙沙, 等. 慢性阻塞性肺疾病患者使用吸入裝置的用藥評價與分析. 中國臨床藥理學雜志, 2019, 35(11): 1179-1182.
26. 何勝東, 楊樹棟, 何新兵, 等. 慢性阻塞性肺疾病患者干粉吸入裝置操作錯誤情況及影響因素研究. 中國全科醫學, 2020, 23(7): 819-823.
27. Horváth A, Farkas á, Szip?cs A, et al. Numerical simulation of the effect of inhalation parameters, gender, age and disease severity on the lung deposition of dry powder aerosol drugs emitted by Turbuhaler?, Breezhaler? And Genuair? in COPD patients. Eur J Pharm Sci, 2020, 154: 105508.
28. Baloira A, Abad A, Fuster A, et al. Lung deposition and inspiratory flow rate in patients with chronic obstructive pulmonary disease using different inhalation devices: a systematic literature review and expert opinion. Int J Chron Obstruct Pulmon Dis, 2021, 16: 1021-1033.
29. Tarsin W, Assi KH, Chrystyn H. In-vitro intra- and inter-inhaler flow rate-dependent dosage emission from a combination of budesonide and eformoterol in a dry powder inhaler. J Aerosol Med, 2004, 17(1): 25-32.
30. Schreiber J, Sonnenburg T, Luecke E. Inhaler devices in asthma and COPD patients -- a prospective cross-sectional study on inhaler preferences and error rates. BMC Pulm Med, 2020, 20(1): 222.
31. Talaat M, Si X, Xi J. Effect of Mdi actuation timing on inhalation dosimetry in a human respiratory tract model. Pharmaceuticals (Basel), 2022, 15(1): 61.
32. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College Of Chest Physicians/American College Of Asthma, Allergy, And Immunology. Chest, 2005, 127(1): 335-371.
33. Ding B, Small M, Scheffel G, et al. Maintenance inhaler preference, attribute importance, and satisfaction in prescribing physicians and patients with asthma, COPD, or asthma-copd overlap syndrome consulting for routine care. Int J Chronic Obstr, 2018, 13: 927-936.
34. Trushenko NV, Stoliarevich AA, Andriukov BG, et al. Assessment of inhalation technique in patients with bronchial asthma and chronic obstructive pulmonary disease. Ter Arkh, 2023, 95(3): 210-216.
35. Marko M, Pawliczak R. Inhalation technique-related errors after education among asthma and COPD patients using different types of inhalers - systematic review and meta-analysis. NPJ Prim Care Respir Med, 2025, 35(1): 15.
36. Dabrowska M, Luczak-Wozniak K, Miszczuk M, et al. Impact of a single session of inhalation technique training on inhalation skills and the course of asthma and COPD. Respir Care, 2019, 64(10): 1250-1260.
37. Harb HS, Laz NI, Rabea H, et al. First-time handling of different inhalers by chronic obstructive lung disease patients. Exp Lung Res, 2020, 46(7): 258-269.
38. Melani AS, Bonavia M, Mastropasqua E, et al. Time required to rectify inhaler errors among experienced subjects with faulty technique. Respir Care, 2017, 62(4): 409-414.
39. He JL, Xu HQ, Yang J, et al. Fear of disease progression among breast cancer patients in china: a meta-analysis of studies using the fear of progression questionnaire short form. Front Psychol, 2023, 14: 1222798.
40. Finset A. Living well with COPD: illness beliefs, self-management support, patient involvement in decisions and inhaler education. Patient Educ Couns, 2020, 103(4): 675-676.
41. 中國醫學裝備協會呼吸病學專委會吸入治療與呼吸康復學組, 中國慢性阻塞性肺疾病聯盟. 穩定期慢性氣道疾病吸入裝置規范應用中國專家共識. 中華結核和呼吸雜志, 2019, 42(4): 241-253.
42. Boise E, Rotella M. Abcs of asthma inhaler and device training. Int Forum Allergy Rhinol, 2015, 5 Suppl 1: S71-S75.
43. Ahn JH, Chung JH, Shin KC, et al. The effects of repeated inhaler device handling education in COPD patients: a prospective cohort study. Sci Rep, 2020, 10(1): 19676.
44. Brusselle G, Himpe U, Fievez P, et al. Evolving to a single inhaler extrafine LABA/LAMA/ICS - inhalation technique and adherence at the heart of COPD patient care (Trivolve). Respir Med, 2023, 218: 107368.

Chinese Journal of Respiratory and Critical Care Medicine

Status of inhaler technique and influencing factors among patients with chronic respiratory diseases in southwest China

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content